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Foodborne Illness:
Another Way the Poor Pay More
Thomas Gremillion
CFA Director of Food Policy
Nick Roper
CFA Administrative & Advocacy Associate
November, 2020
Foodborne Illness: Another Way the Poor Pay More | CFA 1
Introduction
In 1967, David Caplovitz published The Poor Pay More, which documented how poor
families in New York City housing projects paid more for the same goods and services as their
more affluent neighbors. Caplovitz’s landmark sociology study is a part of rich tradition of
consumer advocacy seeking to shine a light upon, and ultimately undo, the “poverty penalties”
that affect consumers across the economy, from consumer finance to product safety.1
This report examines the “poverty penalty” wrought by the food system in the form of
foodborne illness. Foodborne illness represents a serious public health threat, with significant
economic consequences for consumers. According to researchers at the U.S. Centers for Disease
Control and Prevention (CDC), each year an estimated one in six U.S. consumers suffers a
foodborne illness, with 128,000 hospitalized and 3,000 dying.2 A number of risk factors
determine who is most likely to suffer from foodborne illness. Some of these, such as
international travel, eating raw oysters, or dining out, fall squarely within an individual’s control.
Others, such as the sanitation and refrigeration capacity at the neighborhood grocer, reflect
systemic conditions.
In the United States, poor consumers, particularly children, are more likely to suffer from
many types of foodborne illness, despite being less likely to engage in many higher risk
behaviors.3 This report explores some the causes of this disparate impact, and strategies for
reducing the burden of foodborne illness on the poor.
A Preventable Epidemic
Unlike many other diseases, foodborne illness is entirely preventable, yet it imposes an
enormous toll on our public health and economy. The U.S. Department of Agriculture’s
Economic Research Service has estimated that the subset of foodborne illnesses attributable to
specific pathogens—only about 20% of the estimated 48 million illnesses each year—costs
consumers over $15.5 billion each year.4 This price tag reflects only medical costs and
productivity losses, as measured by lost wage estimates. The full cost of foodborne illness,
however, and what consumers would be willing to pay to avoid it, greatly exceed these estimates.
Despite the high costs, progress on reducing foodborne illness has largely stalled in
recent years. In fact, the most recent CDC data shows an upward trend in reported foodborne
illnesses over the last four years.5 The incidence of infections caused by Campylobacter,
Yersinia, Cyclospora, Shiga toxin-producing E. coli (STECs), and Vibrio, rose in 2019 compared
Foodborne Illness: Another Way the Poor Pay More | CFA 2
with the previous three years (2016-2018), while progress in reducing Salmonella, Shigella, and
Listeria infections effectively flat-lined. New culture-independent diagnostic testing (CIDTs)
may account for some of the increase, but CDC researchers have made clear that “identification
of infections that might not have been detected before adoption of CIDTs cannot explain this
overall lack of progress.”6 What’s more, the lack of progress has disproportionately affected the
poor, who suffer increased rates of foodborne illness, according to recent studies.
Measurement Challenges
Research on foodborne illness and poverty has been beset by measurement challenges. In
general, uncertainty poses a major barrier to more effective policy, public and private, to prevent
foodborne illness. Perhaps most importantly, strategies to curb most foodborne pathogens are
missing a key feedback mechanism because the vast majority of foodborne illness infections
simply go unreported.
The most costly foodborne pathogen, Salmonella, illustrates this problem. Each year,
Salmonella causes an estimated 1.35 million illnesses, 26,500 hospitalizations, and 420 deaths in
the United States,7 at an estimated cost of $3.7 billion in medical bills alone.8 The bacterium
causes more hospitalizations and deaths than any other microbiological pathogen in the U.S.
food supply, but most victims do not seek medical care.9 For those who do, they may
nevertheless receive an incorrect diagnosis, because the symptoms of Salmonella infection vary
from one patient to the next. Fever, abdominal cramps, and diarrhea are among the most
common signs, but many infections do not manifest these symptoms. In the initial stages of
infection, only a stool sample can confirm whether Salmonella is the cause, and if a person takes
antibiotics before a diagnostic test is performed, a false negative may result. Even where a
patient seeks medical care and provides a specimen, and laboratory testing confirms
salmonellosis, those results may not necessarily be reported to public health authorities. As a
result, CDC researchers estimate that for every reported case of Salmonella infection, another 29
go unreported.10
This uncertainty obscures the extent to which foodborne illness affects consumers, and
measuring the burden of foodborne illness on poor consumers in particular faces additional
obstacles. One of these arises out of uneven access to healthcare. Epidemiologists have estimated
that individuals with health insurance are three times as likely to submit a stool sample as
individuals without health insurance.11 Simply identifying patients who are living in poverty
poses a challenge as well. In the United States, the best data on foodborne illness is available via
Foodborne Illness: Another Way the Poor Pay More | CFA 3
the Foodborne Diseases Active Surveillance Network, or FoodNet. However, CDC and the state
and local public health partners that contribute to FoodNet do not track income or other
indicators of socioeconomic status in their reporting. FoodNet data poses an additional challenge
by virtue of the geographic areas from which its data is gathered. As researchers have explained,
the FoodNet “catchment area was not chosen to equally represent all racial and ethnic groups,
and even in the expanded FoodNet population, Hispanics and those living below the poverty
level are underrepresented when compared to the general American population (6% vs. 12%, and
11 vs. 14%, respectively).”12
The Toll of Foodborne Illness on the Poor
Despite this uncertainty, recent research provides a clear indication that living in poverty
is an important risk factor for acquiring a foodborne illness. By using location data for reported
cases, researchers have analyzed whether living in zip codes with higher rates of poverty makes a
person more likely to report a foodborne illness. Their studies strongly suggest that poverty puts
consumers, particularly those under five years of age, at higher risk of infection from foodborne
pathogens such as Campylobacter, Salmonella, and Shigella.13,14,15
One of the most comprehensive of these recent studies analyzes Salmonella infection
rates across FoodNet sites. Salmonella makes people sick through a diverse array of foods—led
by fresh produce, poultry, and pork. This ubiquity has no doubt helped to make Salmonella the
most economically harmful foodborne pathogen. In a recent FoodNet study, researchers analyzed
52,821 Salmonella infections, reported between 2010 through 2016. They were able to exclude
nearly four thousand of those cases as likely acquired during international travel outside of the
U.S., which eliminated an important confounding variable, since international travel typically
correlates with higher income. The incidence of the remaining “domestic cases” was
“statistically associated with increasing census tract poverty.”16 This association was strongest
for children under five years of age, with children in high poverty census tracts 50% more likely
to report an infection. The study concludes that salmonellosis prevention efforts should carry an
“emphasis on young children living in higher-poverty areas.”
Similar results were documented in other recent studies. In a 2020 study of 23,028
Shigella infections, reported to FoodNet between 2004 and 2014, researchers found that, after
excluding 1,684 patients that reported international travel in the week prior to illness, patients
living in high poverty census tracts (with greater than 20% of the population living below the
federal poverty line) were over three times more likely to report a Shigella infection than their
Foodborne Illness: Another Way the Poor Pay More | CFA 4
counterparts in low poverty areas (less than 5% living in poverty).17 Likewise, in a 2016 study of
Campylobacter infections, researchers found higher incidence of infection “in zip codes with
higher percentages of individuals living below the poverty level.”18
For Listeria, a rare but deadly pathogen associated with foods including sliced deli meats
and raw milk cheeses, a smaller overall number of cases has so far prevented researchers from
conducting similar analyses of the impact of poverty on infection rates. However, racial and
ethnic data collected by FoodNet suggests that a similar dynamic exists.19 As shown in the graph
below, individuals identifying as “Hispanic”—a group with poverty rates more than double those
of “non-Hispanics,”20—suffer from significantly higher rates of listeriosis. Evidence from
outside the United States further buttresses the claim that poverty increases Listeria risk, with a
UK study concluding that “listeriosis incidence was highest in the most deprived areas of
England when compared with the most affluent.”21
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Why the Poor Suffer More from Foodborne Illness
The higher incidence of reported foodborne illnesses in areas with higher poverty levels
raises serious concerns, particularly since so many factors would seem to support opposite
results. Poor consumers are less likely to have reliable access to healthcare and therefore are less
likely to have a foodborne illness reported. The poor also have less access to “high-risk” foods—
in particular fresh produce, which accounts for an estimated 17% of Salmonella illnesses, and
nearly half of all reported foodborne illnesses each year;22 they are less likely to eat raw foods,
including raw oysters and raw beef; and they are less likely to dine out. All of these are
significant risk factors for acquiring a foodborne illness.
On the other hand, cultural practices around food may contribute to more foodborne
illness among poor consumers. According to census data, the poverty rates for Blacks and
Hispanics is more than double that of non-Hispanic Whites.23 One recent study found that
“minority consumers were significantly more likely than Caucasian consumers (p<0.05) to
purchase live poultry and to purchase eggs unrefrigerated,” and “were also more likely to report
cooking offals [the entrails and internal organs of food animals] and cooking a whole turkey
overnight,” practices associated with a high risk of cross-contamination and temperature abuse,
respectively.24 Researchers have hypothesized that consumption of “fresh Mexican-style
cheeses” (see photo at right below) may explain why FoodNet data includes over five times as
many reported cases of listeriosis suffered by Hispanic pregnant women, as compared to non-
Hispanic pregnant women, since the cheeses are associated with an increased risk of Listeria
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infection.25 Similarly, eating chitterlings—or hog intestines (see photo at left below)—may
account for an increased incidence of yersiniosis among African-Americans.26
There is also some evidence of heightened foodborne illness risk in retailers that service
poor communities. One recent study indicates that “small, independently owned corner markets
operating in urban areas with populations of low socioeconomic status (SES) may experience
barriers to food safety including pest infestation, poor infrastructure and refrigeration, language,
limited resources, and small or untrained staff.”27 The study compared food samples taken from
corner stores in poorer areas, with similar samples from larger supermarkets and chain
convenience markets in more affluent census tracts within the Philadelphia metropolitan region,
and found higher levels of bacteria contamination on products like fresh produce and milk in the
corner stores.28
Such evidence lends support for certain targeted interventions, such as education
campaigns focused on risky food handling practices among some groups,29 or fully funding state
and local health departments that inspect local food retailers.30 However, the most significant
source of vulnerability to foodborne illness likely has nothing to do with how a consumer
prepares food or where she shops.
The harsh reality is that living in poverty itself represents a risk factor for a wide range of
health problems, including foodborne illness.31 According to one recent study of national survey
data collected during 2010–2016, children from low-income households were significantly more
likely to have suffered a recent bout of gastrointestinal or respiratory illness, compared to their
peers in higher income households.32 This reflects, in part, a lack of access to nutritious foods.
Over 23 million U.S. consumers, about half of whom are “low-income,” live in a food desert.33
While this may translate into fewer foodborne illness cases attributable to fresh produce, it likely
increases the burden of foodborne illness overall, because poor nutrition makes individuals more
vulnerable to foodborne illness.34
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The dynamics behind this increased vulnerability are straightforward. Researchers have
noted that poor nutrition is “well understood to impair immune function,” in part because it tends
to “impair the production and activity of immune cells and antibodies.”35,36 A weakened or
compromised immune system can, in turn, increase one’s risk for infection, including from
foodborne illness. Studies have shown, for example, that poor nutrition leads to reduced gut
health, which in turn stymies the body’s ability to fight off Salmonella infections.37 As a result of
these factors, consumers struggling with the stresses of scarcity tend to be the least equipped to
fend off foodborne pathogens that pose a threat to all consumers.
Action Steps: How to Protect the Poor from Foodborne
Illness
Foodborne illness disproportionately affects people—particularly children—living in
poverty, and this fact strengthens the case for reforms to improve food safety. Some policies,
such as education campaigns38 or retail inspection strategies,39 may target sources of foodborne
illness that particularly affect low-income communities. The most important food safety reforms
needed to protect the poor, however, also happen to be those that will reduce foodborne illness
among the entire population. Here are five suggested food safety reforms:
• Protect consumers from meat and poultry adulterated with virulent Salmonella:
Current regulations allow meat and poultry processors to sell product
contaminated with dangerous Salmonella bacteria. With tools such as vaccines
and closer monitoring of live animals, producers outside of the U.S. have
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achieved significant progress in reducing the toll of salmonellosis. 40 Regulators in
the U.S. can make similar progress by declaring outbreak serotypes of Salmonella
to be adulterants under federal law. 41 As a first step, USDA should immediately
disclose the data it already collects to the public in real time. 42 This data identifies
when a meat or poultry product has tested positive for an outbreak strain of
Salmonella, i.e. a strain genetically identical to one collected from a cluster of
illness victims.
• Make fresh produce safer: Recent outbreaks of E.coli O157:H7 linked to romaine
lettuce and other fresh produce have killed at least six people and sickened an
untold number of consumers.43 The evidence indicates that the deadly bacteria
originated in cows, with one recent romaine lettuce outbreak linked to a nearby
feedlot that holds more than 100,000 head of cattle at a time.44 To avoid future
outbreaks, federal regulators should follow through on rules requiring sanitization
of agricultural water. Congress should also hold cattle producers accountable,
through laws such as the Expanded Food Safety Investigation Act of 2019, which
would give regulators authority to conduct microbiological sampling on
concentrated animal feeding operations (CAFOs).45 Policymakers should also
consider incentives for cattle producers to vaccinate cattle against E.coli, an
option that has been commercially available for the past five years, but seldom
used because it does not boost profitability for feedlot operators.46 Vaccinating
cattle against dangerous E.coli would improve the safety of both beef, and foods
grown in the vicinity of cattle, i.e. almost everything.
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• Slow the rise of superbugs: Approximately 70% of all medically important
antibiotics in the United States are sold for use in animals.47 This widespread use
generates antibiotic resistance. Antibiotic resistance in foodborne pathogens, like
Salmonella, is associated with a greater risk of hospitalization and death in
infected individuals.48 Overall, antibiotic-resistant infections kill an estimated
23,000 Americans each year.49 The threat of antibiotic resistance demands a
comprehensive response from Congress, such as the Preservation of Antibiotics
for Medical Treatment Act, long championed by the late Rep. Louise Slaughter.50
In the meantime, federal regulators should pursue policies to reduce animal
antibiotic overuse. A good start would be to create a system to collect data on how
antibiotics are used on-farm, including information on quantities of antibiotics
used and the specific indications for use.51
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• Promote a culture of food safety in the workplace: Food workers are on the front
lines of the fight to prevent foodborne illness. Yet workers who lack basic
workplace safety protections, including paid sick leave, cannot be expected to
contribute to the attitudes, values and beliefs that make a successful culture of
food safety possible. More and more companies have embraced this reality, but
for others, rules are needed. At the outset of the COVID-19 pandemic, USDA
announced a decision to allow several large poultry processors to increase their
line speeds, rather than directing them to slow their lines to reduce worker
crowding and make it possible to maintain social distancing.52 More recently,
USDA officials have interceded on behalf of meatpackers in discussions with
local health departments that sought to protect workers and their communities
from COVID-19.53 The opposite approach would better promote food safety. The
pandemic has highlighted the importance of paid sick leave in particular as a
critical protection for workers. Sick leave is also important to reduce foodborne
illness directly, with CDC estimating that sick food workers cause hundreds of
foodborne illness outbreaks every year.
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• Create a single, independent food safety agency: 15 different federal agencies
currently divvy up responsibility for ensuring the safety of the food supply. The
U.S. Department of Agriculture simultaneously promotes and polices U.S. food
producers, a glaring conflict that has led to predictable lapses in protection for
consumers. The Safe Food Act, most recently introduced by Rep. Rosa DeLauro
and Sen. Richard Durbin in 2019, would consolidate federal food safety activities
into one independent single food safety agency, with broad jurisdiction to address
food safety hazards wherever they may emerge.54
Conclusion
Foodborne illness affects everyone, and consumers will have to contend with some
foodborne illness risk no matter what precautions are taken. But that does not justify neglecting
cost-effective, practical solutions that will improve food safety. The benefits of these policies
will disproportionately flow to the poor, and particularly to children living in poverty, because
they are disproportionately hurt by foodborne illness. That fact should provide added motivation
for action.
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1 See, e.g., Mierzwinski, E. (2010). "Colston E. Warne Lecture: Consumer Protection 2.0-Protecting Consumers in
the 21st Century". Journal of Consumer Affairs. 44 (3): 578–597. doi:10.1111/j.1745-6606.2010.01185.x 2 Centers for Disease Control and Prevention. (2020, March 18). Foodborne Germs and Illnesses. Retrieved
November 17, 2020, from https://www.cdc.gov/foodsafety/foodborne-germs.html. 3 Quinlan, J. J. (2013, August 15). Foodborne illness incidence rates and food safety risks for populations of low
socioeconomic status and minority race/ethnicity: A review of the literature. Retrieved November 17, 2020, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774461/. 4 Hoffmann, S., Maculloch, B., & Batz, M. (2015, May). Economic Burden of Major Foodborne Illnesses Acquired
in the United States. Retrieved November 17, 2020, from
https://www.ers.usda.gov/webdocs/publications/43984/52807_eib140.pdf. 5 Tack, D. M. et. al. (2020, May 1). Preliminary Incidence and Trends of Infections with Pathogens Transmitted
Commonly Through Food - Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2016–2019. Retrieved
November 17, 2020, from https://www.cdc.gov/mmwr/volumes/69/wr/mm6917a1.htm?s_cid=mm6917a1_w.c. 6 Ibid. 7 Centers for Disease Control and Prevention. (2020, October 16). Salmonella Homepage. Retrieved November 17,
2020, from https://www.cdc.gov/salmonella/index.html. 8 U.S. Department of Agriculture & Economic Research Service. (2020, August 20). Cost Estimates of Foodborne
Illnesses. Retrieved November 17, 2020, from https://www.ers.usda.gov/data-products/cost-estimates-of-foodborne-
illnesses.aspx. 9 Centers for Disease Control and Prevention. (2020, October 16). Salmonella Homepage. Retrieved November 17,
2020, from https://www.cdc.gov/salmonella/index.html. 10 Scallan, E. et. al. (2011, January). Foodborne illness acquired in the United States--major pathogens. Retrieved
November 17, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3375761/. 11 Scallan, E. et. al. (2006, Winter). Factors associated with seeking medical care and submitting a stool sample in
estimating the burden of foodborne illness. Retrieved November 17, 2020, from
https://pubmed.ncbi.nlm.nih.gov/17199525/. 12 Cesar, M. J. (2018). Poverty Rate and Occurrence of Foodborne Illness Risk Factors in Retail Facilities. Retrieved
November 17, 2020, from
https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=6205&context=dissertations. 13 Rosenberg Goldstein, R. E., et. al. (2016, July 22). Association between community socioeconomic factors,
animal feeding operations, and campylobacteriosis incidence rates: Foodborne Diseases Active Surveillance
Network (FoodNet), 2004–2010. Retrieved November 17, 2020, from
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-016-1686-9. 14 Hadler, J. L. et. al. (2019, November 23). Relationship Between Census Tract–Level Poverty and Domestically
Acquired Salmonella Incidence: Analysis of Foodborne Diseases Active Surveillance Network Data, 2010–2016.
Retrieved November 17, 2020, from https://academic.oup.com/jid/article/222/8/1405/5638199. 15 Libby, T. et. al. (2020, January 31). Disparities in Shigellosis Incidence by Census Tract Poverty, Crowding, and
Race/Ethnicity in the United States, FoodNet, 2004-2014. Retrieved November 17, 2020, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7032626/. 16 Hadler, J. L. et. al. (2019, November 23). Relationship Between Census Tract–Level Poverty and Domestically
Acquired Salmonella Incidence: Analysis of Foodborne Diseases Active Surveillance Network Data, 2010–2016.
Retrieved November 17, 2020, from https://academic.oup.com/jid/article/222/8/1405/5638199. 17 See Table 1. Libby, T. et. al. (2020, January 31). Disparities in Shigellosis Incidence by Census Tract Poverty,
Crowding, and Race/Ethnicity in the United States, FoodNet, 2004-2014. Retrieved November 17, 2020, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7032626/. 18 Rosenberg Goldstein, R. E., et. al. (2016, July 22). Association between community socioeconomic factors,
animal feeding operations, and campylobacteriosis incidence rates: Foodborne Diseases Active Surveillance
Network (FoodNet), 2004–2010. Retrieved November 17, 2020, from
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-016-1686-9. 19 Quinlan, J. J. (2013, August 15). Foodborne illness incidence rates and food safety risks for populations of low
socioeconomic status and minority race/ethnicity: A review of the literature. Retrieved November 17, 2020, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774461/. 20 U.S. Census Bureau. (2020, September 15). Poverty Rates for Blacks and Hispanics Reached Historic Lows in
2019. Retrieved November 17, 2020, from https://www.census.gov/library/stories/2020/09/poverty-rates-for-blacks-
and-hispanics-reached-historic-lows-in-2019.html.
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21 Gillespie, I. A., et. al. (2010, July 8). Human listeriosis in England, 2001-2007: Association with neighbourhood
deprivation. Retrieved November 17, 2020, from https://pubmed.ncbi.nlm.nih.gov/20630146/.
22 The Interagency Food Safety Analytics Collaboration (IFSAC). (2019, September). Foodborne illness source
attribution estimates for 2017 for Salmonella, Escherichia coli O157, Listeria monocytogenes, and Campylobacter
using multi-year outbreak surveillance data, United States. Retrieved November 17, 2020, from
https://www.cdc.gov/foodsafety/ifsac/pdf/P19-2017-report-TriAgency-508-archived.pdf. 23 U.S. Census Bureau, & Creamer, J. (2020, September 15). Poverty Rates for Blacks and Hispanics Reached
Historic Lows in 2019. Retrieved November 17, 2020, from
https://www.census.gov/library/stories/2020/09/poverty-rates-for-blacks-and-hispanics-reached-historic-lows-in-
2019.html 24 Henley, S., Stein, S. E., & Quinlan, J. J. (2015, December). Characterization of raw egg and poultry handling
practices among minority consumers. Retrieved November 17, 2020, from
https://www.researchgate.net/publication/283829021_Characterization_of_raw_egg_and_poultry_handling_practice
s_among_minority_consumers. 25 Quinlan, J. J. (2013, August 15). Foodborne Illness Incidence Rates and Food Safety Risks for Populations of
Low Socioeconomic Status and Minority Race/Ethnicity: A Review of the Literature. Retrieved November 17, 2020,
from https://www.mdpi.com/1660-4601/10/8/3634/htm. 26 Ibid. 27 Signs, R. J., et. al. (2011, October). Retail food safety risks for populations of different races, ethnicities, and
income levels. Retrieved November 17, 2020, from https://pubmed.ncbi.nlm.nih.gov/22004820/. 28 Ibid. 29 United States Department of Agriculture, & Food Safety and Inspection Service. (2011, February). Yersiniosis
and Chitterlings: Tips to Protect You and Those You Care for from Foodborne Illness. Retrieved November 17,
2020, from https://www.fsis.usda.gov/wps/wcm/connect/fa876273-5a27-422c-b0d7-
6254521269dc/Yersiniosis_and_Chitterlings.pdf?MOD=AJPERES. See also: United States Department of
Agriculture, & Food Safety and Inspection Service. (2011, May). Ratites (Emu, Ostrich, and Rhea). Retrieved
November 17, 2020, from https://www.fsis.usda.gov/wps/wcm/connect/5b49da82-39a8-4722-bcce-
a85bcd1d8833/Ratites_Emu_Ostrich_Rhea.pdf?MOD=AJPERES. 30 Trust for America's Health. (2018, March). A Funding Crisis for Public Health and Safety: State-by-State Public
Health Funding and Key Health Facts. Retrieved November 17, 2020, from https://www.tfah.org/report-details/a-
funding-crisis-for-public-health-and-safety-state-by-state-and-federal-public-health-funding-facts-and-
recommendations/. 31 See, e.g. Wood, D. (2003, September). Effect of Child and Family Poverty on Child Health in the United States.
Retrieved November 17, 2020, from
https://pediatrics.aappublications.org/content/pediatrics/112/Supplement_3/707.full.pdf. 32 Berendes, D. (2020, January 17). Correction and Republication: Associations Among School Absenteeism,
Gastrointestinal and Respiratory Illness, and Income-United States, 2010 – 2016. Retrieved November 17, 2020,
from https://www.cdc.gov/mmwr/volumes/69/wr/mm6902a5.htm?s_cid=mm6902a5_w. 33 U.S. Department of Agriculture, & Economic Research Service. (2009, June). Access to Affordable and
Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences. Retrieved November 17,
2020, from https://www.ers.usda.gov/webdocs/publications/42711/12716_ap036_1_.pdf. 34 See, e.g. Smith, J. L. (1998, September 01). Foodborne Illness in the Elderly. Retrieved November 17, 2020, from
https://meridian.allenpress.com/jfp/article/61/9/1229/168212/Foodborne-Illness-in-the-Elderly. 35 Harvard School of Public Health. (n.d.). Nutrition and Immunity. Retrieved November 17, 2020, from
https://www.hsph.harvard.edu/nutritionsource/nutrition-and-immunity/. 36 Childs, C. E., Calder, P. C., & Miles, E. A. (2019, August 11). Diet and Immune Function. Retrieved November
17, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723551/. 37 Brown, E. M., et. al. (2015, August 4). Diet and specific microbial exposure trigger features of environmental
enteropathy in a novel murine model. Retrieved November 17, 2020, from
https://pubmed.ncbi.nlm.nih.gov/26241678/. 38 See, e.g., Henly supra note 20. 39 See, e.g. Pothukuchi, K., Mohamed, R., & Gebben, D. A. (2008, March 8). Explaining disparities in food safety
compliance by food stores: Does community matter? Retrieved November 17, 2020, from
https://link.springer.com/article/10.1007/s10460-008-9132-2.
Foodborne Illness: Another Way the Poor Pay More | CFA 14
40 Gremillion, T. (2018, November 27). Taking Salmonella Seriously Policies to Protect Public Health under Current
Law. Retrieved November 17, 2020, from https://consumerfed.org/wp-content/uploads/2018/11/taking-salmonella-
seriously-policies-to-protect-public-health-under-current-law.pdf. 41 Clark, M. et. al. (2020, January 19). Petition for an Interpretive Rule Declaring ‘Outbreak’ Serotypes of
Salmonella enterica subspecies enterica to be Adulterants Within the Meanings of 21 U.S.C. § 601(m)(1) and ) 21
U.S.C. § 453(g)(1). Retrieved November 17, 2020, from https://www.fsis.usda.gov/wps/wcm/connect/d2a7c76e-
dda9-475d-bf35-4cb69f5fca24/20-01-marler-011920.pdf?MOD=AJPERES. 42 Gremillion, T. (2020, January 04). We need a clear vision into food safety for 2020. Retrieved November 17,
2020, from https://thehill.com/opinion/energy-environment/476715-we-need-a-clear-vision-into-food-safety-for-
2020. 43 Centers for Disease Control and Prevention. (2020, September 24). List of Selected Multistate Foodborne
Outbreak Investigations. Retrieved November 17, 2020, from https://www.cdc.gov/foodsafety/outbreaks/multistate-
outbreaks/outbreaks-list.html. 44 U.S. Food and Drug Administration. (2019, November). Outbreak Investigation of E. coli: Romaine (November
2019). Retrieved November 17, 2020, from https://www.fda.gov/food/outbreaks-foodborne-illness/outbreak-
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